cep.health/preconceptionUpdated October 2018 Page 1 of 3

q Provide brief intervention and provide appropriate referrals.11 q Inform women of available patient resources12 and

Smokers’ Helpline 1-877-513-5333.q Consult Canadian Smoking Cessation Guidelines.13 q Counsel women with tobacco addictions of risks of pregnancy

and relapse. q Strategize management.q Recommend an extra 35 µg of vitamin C daily for smokers.

Providers

Patient Name:

Birth Date:

Preconception health care involves identifying potential physical, genetic, psychosocial, environmental and behavioural risk factors for adverse pregnancy outcomes, and reducing those risks prior to conception through counselling, educa-tion and intervention. Preconception Health Care focuses on health promotion and illness prevention for everyone of reproductive age. It is an important opportunity for primary care providers to improve maternal and infant outcomes, as the critical period for fetal development often occurs before prenatal care begins. Each of the preconception topics below should be addressed with every individual of reproductive age on an ongoing basis.

q No Discuss contraception options.q Not sure Choosing Wisely Tool.2 q Inform women of reproductive age that natural

fertility and assisted reproductive technology success is significantly lower for women in their late 30-40s.3

q If positive pregnancy test, discuss options for prenatal care and refer accordingly.

q Yes.4 LMP:_______________q Discuss family planning and conception.

Prevent & promote Screen Manage

Preconception Health Care Tool

Inform all individuals of sexual health risks associated with travel to countries with reported Zika infection. Recommend patients wait 6 months following travel to attempt conception due to potential for transmission through sperm.41

q Chlamydia q Syphilis q Trichomoniasis

q Gonorrhea q Genital herpes (if lesions)

Screen if high risk: q Provide treatment according to Canadian Guidelines on Sexually Transmitted Infections.5

q Inform women with genital herpes of risk of vertical transmission.

Gravida (G):______________ Abortions (A):______________ Full-term (T):_____________ Living children (L): _________ Premature (P):____________

Details:

q Provide appropriate referrals.q Inform women who have had prior caesarean sections that

vaginal birth is an option for their next pregnancy.40

q Recommend folic acid 5mg daily prior to conception and for 12 weeks after conception if positive history of neural tube defect.

q Recommend >18 and <59 month interpregnancy interval (IPI).

Inquire about previous pregnancies:

q Preterm Birth

q Preeclampsia

q Congenital anomalies

q Stillbirthq Miscarriageq Assisted

reproductive technologies

q Gestational DM

q Caesarean birth

q Uterine anomalies

q High/low birth weight

Human teratogenicity risk is unknown for the majority of medications. Use caution when prescribing for women of reproductive age. Consult Motherisk.6

Potentially teratogenic medications should be changed to safer options. Women should be counselled not to stop prescribed medications without consulting with their provider.q Recommend folic acid 5mg daily prior to conception and for

12 weeks after conception for women taking folate antagonists (ex. methotrexate, sulfonamides and antiepileptics).

Screen for teratogenic medication use:q Prescribed medicationsq Over-the-counter medicationsq Complementary and alternative therapy (herbal, natural,

weight loss, athletic products or supplements, etc.)

Promote mental health wellness through adequate sleep, work-life balance, stress reduction and social connectedness.

q Depression8

q Anxiety9

q Other 1 0

q Screen for family history of mental health issues.

q Bipolar disorder q Mood disorder q Schizophrenia q Counsel women with mental health diagnoses of risks

of pregnancy and relapse. Strategize management.q Stabilize/optimize mood and anxiety level; discuss risks

and benefits of medications.

Screen:

Encourage all individuals to be tobacco free prior to conception. q Tobacco (all forms)q Tobacco exposure (second-hand smoke)

Screen:

Chronic medical conditions: Optimize management for the following diseases, as suboptimal control or treatments can increase risk for adverse maternal and/or infant outcomes.

For more information regarding preconception chronic disease management, visit the Before, Between, & Beyond Pregnancy Preconception Care Clinical Toolkit.7

Reproductive life plan: Ask all individuals of reproductive age, “Would you like to have a child in the next year?” Encourage all individuals to make a Reproductive Life Plan.1

Reproductive history: A detailed reproductive history should be obtained for all individuals.

Sexual health:

Medications:

Mental health:

Tobacco use:

Motherisk6 should be consulted for the safety of any medications taken by patients with chronic conditions. Motherisk Helpline: 1-877-439-2744

q Asthma: Delay conception until good control is achieved.

q Cancer: All individuals with cancer should be counselled regarding the potential effects of treatment on fertility and informed of options to preserve fertility, if desired, and referred appropriately.

q Diabetes: Increased risk of birth defects can be mitigated with good preconception glycemic control. Encourage contraception for those without good control. Folic acid 5mg daily prior to conception and for 12 weeks after conception. ACE-Is and statins are contraindicated. Estrogen-containing contraception options should be avoided for those with DM >20 years or target end-organ damage.

q HIV: Transmission risk to fetus is ~2% with antiretroviral therapy. Efavirenz is contraindicated. Antiretroviral drugs may interfere with hormonal contraceptive methods. Refer to specialist.

q Hypertension: Increased risk for adverse fetal and maternal outcomes. Assess for target-end organ damage in those with long-standing hypertension. Alternatives to ACE-Is are recommended in women of reproductive age. Avoid estrogen-containing contraception options for women with severe hypertension.

q Inflammatory bowel disease: Counsel women to delay conception until disease is in remission. Conception during active episode increases risk of miscarriage, premature delivery, still birth or low birth weight.

q Phenylketonuria: Encourage maintenance of low phenylalanine level during reproductive years and especially prior to conception.

q Renal disease: Encourage optimal control prior to conception, including normal BP. Use alternative to ACE-Is. Consult with specialist.

q Seizure disorder: Discuss potential pregnancy outcomes related to seizures and seizure medications. Take folic acid 4-5mg daily prior to conception and for 12 weeks after conception. Lowest dose of one medication recommended, when possible. Valproic acid, lithium and topiramate are contraindicated. Many antiepileptic medications may interfere with hormonal contraceptive methods.

q Systemic lupus erythematosus, rheumatoid arthritis, and other autoimmune diseases: Delay conception until good control is achieved. Discuss natural history of disease during/after pregnancy. Cyclophosphamide, Methotrexate and Leflunomide are contraindicated. Avoid estrogen-containing contraception options in women with SLE and positive/unknown antiphospholipid antibody. Discuss use of aspirin and heparin with rheumatologist for women with SLE and antiphospholipid antibody syndrome.

q Thromboembolic disease: Counsel women that risk for VTE during pregnancy and postpartum is increased, and many will require anticoagulation treatment. Coumadin is contraindicated. Avoid estrogen-containing contraceptive options.

q Thyroid disease: Achieve euthyroid state prior to conception. Women with hypothyroidism should increase their dose of levothyroxine by 30% as soon as pregnancy occurs. Radioactive iodine is contraindicated. Screen all women for CBC and TSH, prior to conception.

cep.health/preconceptionUpdated October 2018 Page 2 of 3

q Access to careq Social isolation (newcomers,

language barriers)34

q Social supportq Workplace stress

q Recommend avoiding fish high in mercury38 : Choose “light” verses “white” tuna and limit consumption to 4 x 2.5oz/week, and avoid barracuda, marlin, tilefish, tuna steak and any raw fish or shellfish.

q Convey tips for reducing exposures in the home.39

q Advise patients to avoid travelling to countries with risk of Zika infection when planning pregnancy. If travel is necessary, both partners should practice strict mosquito bite prevention measures.43, 44

q Underweight (BMI <18.5) q Overweight (BMI = 25-29.9)q Obese (BMI >30)q Provide appropriate referrals for management.q Recommend folic acid 5mg daily prior to conception and for

12 weeks after conception for obese individuals.q Discuss recommended healthy weight gain32 during pregnancy

and recommend contacting EatRight Ontario 1-877-510-5102.

q Recommend folic acid 0.4-1.0mg daily (through a multivitamin or supplement)15 and folate rich diet, prior to conception and throughout pregnancy.

q Recommend calcium 1000mg daily25 through food and/or supplements.q Recommend essential fatty acid rich diet, including omega 3 and 6.q Recommend avoiding raw/undercooked meat and fish and

unpasteurized milk and cheese.26 q Caffeine <300mg/day.27

q Recommend vitamin D 600 IU (15 µg) supplementation daily.28

q Recommend 2.6 µg of vitamin B12 daily through supplement or multivitamin.

Prevent & promote Screen Manage

q Identify stressors and discuss strategies to reduce impact. q Housing q Intimate partner

violence35 q Unemploymentq Financesq Unhealthy relationship

q Inform women that violence often worsens during pregnancy and discuss safety plan.

q Provide appropriate referrals.36

Screen:

Health Canada’s blood methylmercury guidance level in pregnancy or reproductive age: <8mcg/L (40nmol/L).q Refer to local health department if potential water/soil exposure.q Refer to occupational health specialist as needed.

Inquire about exposures to:

q Solvents (ask about use)

q Plasticsq Metals (lead, mercury)q Pollutants

q Pesticidesq Teratogenic and/or gonadotoxic

treatments (chemotherapy, radiation therapy)

q Gasesq Radiation

indicates Canadian resourcesindicates provider resources indicates patient resources

q Provide all immunizations required prior to conception with the exception of the flu vaccine, which can be administered before and/or during pregnancy.

q Varicellaq Rubella

q HPV q Influenzaq Hepatitis B

q Tetanus, Diphtheria, B Pertussis

q Rubellaq Hepatitis Bq Varicella

Vaccinate: Screen for immunity:q Measles, Mumps

q Inform women who screen positive for HIV, Hepatitis B or C of risk for vertical transmission, and offer appropriate treatment.20

q Treat women with Tuberculosis prior to conception.20

q HIVq Parvovirus

q Hepatitis Bq Hepatitis C

q Tuberculosisq Cytomegalovirus

q Toxoplasmosis q HIV

q Hepatitis C q TuberculosisScreen:

Screen if high risk:

q Provide referral to specialist for those with family and genetic history risk factors.

q Recommend folic acid 5mg daily prior to conception and for 12 weeks after conception if positive family history of neural tube defects or high risk ethnic group (ex. Sikh, Celtic, Northern Chinese).

Obtain 3 generation family history to identify21 :q Consanguinity

(first cousins or closer).q Children who died at a young age

(may reveal a metabolic condition).q History of sudden unexplained

death (may indicate cardiomyopathy or metabolic condition).

q History of infertility, multiple miscarriages (>3 or all male fetuses).

q Congenital malformations, birth defects.

q Developmental delays, learning disabilities.

q Ethnicity.q Genetic disorders.22

q Family history of a genetic condition.

Ethnicity Based Screening Considerations23 :

q CBC and/or Hgb Electrophoresis for hemoglobinopathies in African, Mediterranean, Middle Eastern, Asian, Southeast Asian, and Hispanic/South/Central American individuals.

q Cystic Fibrosis mutation in Caucasian individuals if family history present.

q Tay-Sachs in French Canadian individuals if family history present. q Hematopoietic stem cells screening (Ashkenazi Jewish Screening

Panel) for those with Ashkenazi Jewish ancestry.

q Screen BMI31 annually. BMI = weight(kg)/height(m)2

Weight:________________ Height: ________________

BMI: __________________ WC: __________________

Target Body Mass Index (BMI) = 18.5-24.9 (for ages ≥19)

European, African, Eastern Mediterranean, Middle Eastern <102cm

<90cm

<88cm

<80cmSouth Asian, Asian, South and Central American

Waist Circumference (WC)29

Target BMI for ages <1930

Female targetMale target

q Recommend at least 150 minutes of moderate to vigorous aerobic physical activity per week, in episodes of 10 minutes or more. Add muscle and bone strengthening activities at least 2 days per week. See the Canadian Physical Activity Guidelines.33

q Screen for issues regarding access to food, nutrition, storage, cooking facilities and folic acid.

q Screen for iron deficiency anemia if at risk.

q Provide referral to Dietitian or appropriate community agencies.

Infectious diseases: Prevention and screening of these infectious diseases19 are important for those of reproductive age.

Vaccinations and immunity: All individuals of reproductive age should have their immunization status reviewed and updated18 as required.

Family and genetic history:

Nutrition: Eat well with Canada’s Food Guide24.

Weight status: Weight can increase risk of adverse pregnancy outcomes and developing chronic disease.

Physical activity: Being physically active prepares the body for the physical demands of pregnancy and can assist with stress management.

Psychosocial stressors: Stress can have negative affects on pregnancy outcomes.

Environmental exposure: Discuss potential exposure to toxins in occupational and recreational activities.37

Encourage all individuals to be substance free prior to conception. q Alcoholq Other substances

Screen:

Alcohol and other substance use:q Provide brief intervention14 and provide appropriate referrals.q Recommend folic acid 5mg daily prior to conception for those

with addictions.15

q Inform women of available patient resources16 and Drug and Alcohol Helpline 1-800-565-8603.

q Consult low risk drinking guidelines.17

q Consult low risk cannabis use guidelines.42

cep.health/preconceptionUpdated October 2018 Page 3 of 3

References1 Toronto Public Health [Internet]. Toronto (ON): Toronto Public Health; c1998-2018 [cited 2018 Oct 10]. Your

Reproductive Life Plan. 2 Society of Obstetricians and Gynaecologists of Canada [Internet]. Ottawa (ON): Society of Obstetricians and

Gynaecologists of Canada; c2018 [cited 2018 Oct 10]. Choosing Wisely; Helping You Make Decisions About Contraception.

3 Liu K, Case A; Society of Obstetricians and Gynaecologists of Canada. Advanced reproductive age and fertility. Journal of Obstetrics and Gynaecology Canada [Internat]. Nov 2011 [cited 2014 Nov 4];269:1165-1175.

4 BestStart.org [Internet]. Toronto (ON): Health Nexus; c2014 [cited 2014 Oct 15]. 5 Public Health Agency of Canada [Internet]. Ottawa (ON): Public Health Agency of Canada [updated 2018 June

29; cited 2018 Oct 10]. Canadian Guidelines on Sexually Transmitted Infections. 6 Motherisk [Internet]. Toronto (ON): The Hospital for Sick Children (SickKids); c1999-2018 [cited 2018 Oct 10].

Drugs in Pregnancy. 7 Before, Between, & Beyond Pregnancy [Internet]. Atlanta (GA): Preconception health and Health Care initiative

[cited 2014 Oct 15]. Preconception Care Clinical Toolkit: Chronic Disease.8 Maurer DM, Carl R. Screening for depression. Am Fam Physician. 2012 Jan 15;85(2):139-144. 9 Moses S [Internet]. Minneapolis (MN): Family Practice Notebook; c2014 [updated 2013 Nov 12; cited 2014 Oct

15]. Generalized Anxiety Disorder Scale. 10 Centre for Addiction and Mental Health [Internet]. Toronto (ON): Centre for Addiction and Mental Health; c2018

[cited 2018 Oct 10]. Mental Health & Addiction Information A-Z.11 Smokers’ Helpline [Internet]. Toronto (ON): Canadian Cancer Society; c2017 [cited 2018 Oct 10]. Making a

Referral.12 Pregnets [Internet]. Toronto (ON): Centre for Addiction and Mental Health; c2014 [cited 2014 Oct 15]. Smoking

During Pregnancy. 13 CAN-ADAPTT [Internet]. Toronto (ON): Centre for Addiction and Mental Health:

Nicotine Dependence Clinic; c2011 [cited 2014 Oct 15]. Pregnant and Breastfeeding Women.14 Ordean A, Midmer D, Graves L, Payne S, Hunt G; PRIMA (Pregnancy-Related Issues in the Management of

Addictions) Group [Internet]. Department of Family & Community Medicine, University of Toronto; c2004-2012 [updated 2012 Apr; cited 2014 Nov 4].

15 Society of Obstetricians and Gynaecologists of Canada [Internet]. Ottawa (ON): Society of Obstetricians and Gynaecologists of Canada [cited 2018 Nov 13]. Folic Acid: For Preconception and Pregnancy.

16 Drug and Alcohol Helpline [Internet]. London (ON): ConnexOntario Health Services Information; c2018 [cited 2018 Oct 10]. Drug and Alcohol Resources in Canada.

17 Canadian Centre on Substance Abuse [Internet]. Ottawa (ON): Canadian Centre on Substance Abuse; c2014 [cited 2014 Oct 17]. Canada’s Low-Risk Alcohol Drinking Guidelines.

18 Centre for Disease Control and Prevention [Internet]. Atlanta (GA): Centre for Disease Control and Prevention [updated 2016 Nov 14; cited 2018 Oct 10]. Immunization.

19 Before, Between, & Beyond Pregnancy [Internet]. Atlanta (GA): Preconception Health and Health Care initiative [cited 2014 Oct 15]. Preconception Care Clinical Toolkit: Infectious Disease and Immunizations.

20 Centre for Disease Control and Prevention [Internet]. Atlanta (GA): Centre for Disease Control and Prevention [cited 2018 Nov 13]. Pregnancy and HIV, Viral Hepatitis, STD and TB Prevention.

21 GECKO.ca [Internet]. Genetics Education Canada - Knowledge Organization; c2014 [cited 2014 Oct 15]. 22 Wilson DR. Genetic considerations for a women’s pre-conception evaluation. J Obstet Gynaecol Can. 2011

Jan;33(1):57-64. 23 Genetics Education Canada [Internet]. Genetics Education Canada; c2014 [cited 2014 Oct 28]. Ethnicity-based

screening in Canada.

24 Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2011 Sept 1; cited 2014 Oct 15]. Eating Well with Canada’s Food Guide.

25 Dietitians of Canada [Internet]. Toronto (ON): Dietitians of Canada; c2013 [cited 2014 Oct 15]. Calcium. 26 Government of Canada [Internet]. Ottawa (ON): Government of Canada; c2010 [updated 2018 Aug 08; cited

2018 Oct 10]. Food Safety for Pregnant Women. 27 Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2012 Feb 16; cited 2014 Oct 15]. Caffeine in

Food. 28 Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2012 Mar 22; cited 2014 Nov 4]. Vitamin D and

Calcium: Updated Dietary Reference Intakes. 29 Heart and Stroke Foundation [Internet]. Toronto (ON): Heart and Stroke Foundation; c2014 [Cited 2018 Nov

13]. Healthy Waists. 30 Dietitians of Canada [Internet]. Toronto (ON): Dietitians of Canada; c2013 [cited 2014 Oct 15]. BMI Calculator

for Children and Teens. 31 Dietitians of Canada [Internet]. Toronto (ON): Dietitians of Canada; c2013 [cited 2014 Oct 15]. Assess your BMI. 32 Eat Right Ontario [Internet]. Toronto (ON): Dietitians of Canada; c2014 [cited 2014 Oct 15]. Planning to Be

Pregnant? Healthy Tips for Healthy Weight Gain. 33 Canadian Society for Exercise Physiology [Internet]. Ottawa (ON): Canadian Society for Exercise Physiology;

c2014 [cited 2014 Oct 15]. Canadian Physical Activity Guidelines and Canadian Sedentary Behaviour Guidelines.

34 Best Start [Internet]. Toronto (ON): Health Nexus [updated 2014; cited 2014 Oct 15]. Information for Parents New to Canada.

35 Before, Between, & Beyond Pregnancy [Internet]. Atlanta (GA): Preconception health and Health Care initiative [cited 2014 Oct 15]. Preconception Care Clinical Toolkit: Intimate Partner Violence.

36 Public Health Agency of Canada [Internet]. Ottawa (ON): Public Health Agency of Canada [updated 2010 Jan 28; cited 2014 Oct 15]. CPNP Projects Directory Online.

37 Exposure to toxic environmental agents. Committee Opinion No. 575. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:931–5.Exposure to toxic environmental agents. Committee Opinion No. 575. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:931–5. [cited 2018 Nov 13].

38 Toronto Public Health [Internet]. Toronto (ON): Toronto Public Health; c1998-2014 [cited 2014 Oct 15]. Guide to Buying and Eating Fish.

39 Canadian Partnership for Children’s Health & Environment [Internet]. Toronto (ON): Canadian Partnership for Children’s Health & Environment; c2014 [cited 2014 Oct 15]. Creating Healthy Home Environments for Kids: Top 5 Tips.

40 Health Quality Ontario [Internet]. Toronto (ON): Health Quality Ontario; c2018 [cited 2018 Sept 1]. Evidence to improve care: Vaginal birth after caesarean (VBAC).

41 Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2018 Feb 12; cited 2018 Sept 1]. Zika virus: Advice for travellers.

42 Fischer B, Russell C, Sabioni P, van den Brink W, Le Foll B, Hall W, et. al. Lower-risk cannabis use guidelines: A comprehensive update of evidence and recommendations. AJPH Policy 2017;107(8):e1-12

43 Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2018 Mar 15; cited 2018 Sept 1]. Countries with recent or ongoing risk of Zika virus infection.

44 Health Canada [Internet]. Ottawa (ON): Health Canada [updated 2018 Feb 2; cited 2018 Sept 1]. Mosquito bite prevention for travellers.

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The Preconception Health Care Tool is a product of the Centre for Effective Practice. Permission to use, copy, and distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the following paragraphs, and appropriate citations appear in all copies, modifications, and distributions. Use of the Preconception Health Care Tool for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with the Centre for Effective Practice (Email: info@cep.health).

For statistical and bibliographic purposes, please notify the Centre for Effective Practice (info@cep.health) of any use or reprinting of the tool. Please use the below citation when referencing the tool:

Reprinted with Permission from Centre for Effective Practice (October 2018). Preconception Health Care Tool. Toronto: Centre for Effective Practice.

This Tool was developed as part of the Knowledge Translation in Primary Care Initiative which is led by CEP with collaboration from OCFP. Clinical leadership for the development of this tool was provided by Rebekah Barrett MN, NP-PHC and Dr. Deanna Telner MD, MEd, CFPC, FCFP and was subject to external review by primary care providers and other relevant stakeholders. This Tool was funded by the Government of Ontario as part of the Knowledge Translation in Primary Care Initiative.

This Tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice. Primary care providers and other health care professionals are required to exercise their own clinical judgment in using this Tool. Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Government of Ontario, and the contributors to this Tool, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any external sources referenced in this Tool (whether specifically named or not) that are owned or operated by third parties, including any information or advice contained therein.

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